Comparison of Practice Patterns and Outcomes for Recurrent Malignant Pleural Effusions

Abstract

SESSION TITLE: Pleural Effusions SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 29, 2017 at 07:30 AM - 08:30 AM PURPOSE: Guidelines for treatment of recurrent malignant pleural effusions (MPE) recommend use of definitive procedures, such as indwelling pleural catheters (IPC) or pleurodesis, over repeat thoracentesis. However, there is a paucity of comparative effectiveness data assessing the impact of practice patterns on outcomes. We hypothesized that many patients receive multiple thoracenteses rather than receiving a definitive procedure as per guidelines and that guideline inconsistent care would result in more pleural procedures and complications. METHODS: Design: Retrospective cohort study of SEER-Medicare data from 2007-2011. The primary outcome was whether patients with rapidly recurring MPE, defined as recurrence within 2 weeks of their first thoracentesis, received guideline consistent care. Secondary outcomes included subsequent pleural procedures, pneumothorax from pleural procedures, location of care, and inpatient days associated with pleural procedures. Setting: Community and academic practices. Participants: Patients age 66-90 diagnosed with their first primary cancer with a MPE that had a thoracentesis were identified using ICD-9 and CPT codes. Thoracentesis for MPE was performed in 23,431 patients. Of these 12,967 (55%) required a second pleural procedure, 8,572 (37%) died without another pleural procedure and 1,892 (8%) were alive without recurrence at last follow-up. Of the 12,967 patients that required a second pleural procedure, 7,565 (58%) had it within 14 days of the first procedure. Exposure variable: Guideline consistent care, defined as a definitive second pleural procedure. RESULTS: Of the 7,565 patients with rapidly recurring MPE’s, only 1,811 (24%) received guideline consistent care. Definitive pleural procedures as compared to repeat thoracentesis for recurrence of MPE resulted in fewer future pleural procedures (0.62 vs. 1.44 procedures per patient respectively, p<0.0001), fewer pneumothoraxes (<0.0037 vs. 0.009 pneumothoraxes per patient, p=0.001), and fewer emergency room procedures (0.02 vs. 0.04 emergency room procedures per patient, p<0.001). However, repeat thoracentesis and IPCs resulted in fewer inpatient days as compared to chest tube or thoracoscopic pleurodesis (0.013 vs. 0.013 vs. 0.085 vs. 0.097 inpatient days per day of life respectively, p<0.001). Factors associated with guidelines consistent care included living in a big metropolitan area, specialists performing the first procedure, having the procedure in the emergency room, younger patient age, and having a diagnosis of lung cancer. CONCLUSIONS: Guideline consistent care using definitive procedures as compared to repeat thoracentesis is associated with fewer future procedures and complications. CLINICAL IMPLICATIONS: Attention to physician training and developing disease management pathways that facilitate prompt follow-up of MPE is needed to address the quality gap observed. DISCLOSURE: The following authors have nothing to disclose: David Ost, Jiangong Niu, Horiana Grosu, Sharon Giordano No Product/Research Disclosure Information